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The powerful relationship between poverty and health has been documented for nearly two centuries. We have long known that a person’s economic position is the strongest predictor of their health status. Being poor means dying sooner and dying sicker.

A Toronto Public Health report released earlier this week concludes that poverty is literally imprinting itself on the lives of Torontonians. The findings presented in the report are grim. Over the past decade, health inequalities between the rich and the poor have persisted. In some cases, they have grown wider. In other words, opportunities to be healthy in the city of Toronto remain as unequally distributed as ever. The report rightfully attributes these inequalities to the social determinants of health — a term that refers to a diverse range of factors including income, education, employment and housing.

We live in a divided city and the deepening of economic cleavages has become a defining feature of our municipal landscape. Income inequality is on the rise. Housing is becoming less affordable. Neighbourhoods are becoming more polarized. And the cost of living has far outpaced individual earnings. In Toronto, as elsewhere, the social determinants of health have suffered significant decline. As the report makes clear, the poorest among our city’s residents have borne the greatest portion of this burden.

These trends have affected the health of the poor in countless ways. They have constrained access to quality health care. They have increased susceptibility to harmful health-related behaviours, such as smoking. They have compromised the adequacy and stability of housing conditions. They have restricted access to nutritious foods. They have heightened exposures to daily experiences of stress and adversity that get under our skin and harm not only our minds but our bodies as well. In fact, what research has shown is that economic conditions underlie almost every pathway leading to almost every health outcome.

So it shouldn’t come as a surprise that, despite a decade of public programs intended to promote health equity, the health status of the poorest Torontonians hasn’t improved. Given what we know about the social determinants of health, the persistence of health inequalities was entirely predictable.

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At the heart of the issue are two important insights provided by our best available science. First, public health programs that are designed to encourage people to alter their lifestyles and behaviours simply do not address the myriad other associations between economic position and health status. Attempts to address any one problem do little to fundamentally interrupt the overall correlation. Second, because public health programs do not address the “causes of the causes,” they are incapable of stemming the tide of new individuals that develop poor health-related behaviours. No sooner has one cohort been exposed to a health promotion program than another cohort is ready and waiting.

Because it has been an inordinately long time since we have improved the economic conditions of the poorest Torontonians, the proverbial writing was already on the wall 10 years ago, foreshadowing our finding today that the health of the poorest Torontonians has not improved.

Other than, perhaps, initially underestimating the role of economic position and overestimating the ability of public health programs to overcome its effects, we find little fault in the actions of Toronto Public Health. Rather, as the science makes clear, the true guardians of our health are the policy-makers that determine whether all Torontonians — and all Canadians, more generally — are able to keep up with the costs of everyday life.

What can we do at this point? We can create widespread recognition that in every instance that our governments fail to redress inequalities, they are undermining the health of our society. We can engage in civic and political action to help pass public policies that reduce the economic distance between the rich and the poor. We can also support organizations that advocate on behalf of these policies, including Toronto Public Health and the labour unions that protect the conditions of low-wage workers.

Health inequalities are one of the most formidable public health problems of our time. The science strongly supports Toronto Public Health’s insights that public health programs are wholly insufficient to alleviate their burden. The solution lies in tackling the unequal distribution of resources that has become a defining feature of our city and our society at large.

Arjumand Siddiqi is assistant professor and Faraz Vahid Shahidi is a doctoral student at the Dalla Lana School of Public Health, University of Toronto. Correspondence should be sent to Ms. Siddiqi at: aa.siddiqi@utoronto.ca

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